Quality of care for reproductive tract morbidities by rural private practitioners in North India
Reproductive tract morbidities are reported by more than a third of the population in India. In rural areas, practitioners without a formal medical qualification are likely to be the first point of care seeking for these. The aim of this PhD thesis was to contribute to the body of knowledge on quality of care by rural private providers in India. The main objectives were to 1) examine care-seeking for genito-urinary symptoms and community perceptions of provider quality, 2) evaluate rural providers' quality of care, and, 3) examine associations between symptoms, infections and psychological health of care seekers. A combination of qualitative and quantitative methods were used: focus group discussions, household interviews, observations of patient-provider interactions (60 providers; 367 patients) and laboratory investigations for common reproductive tract infections. Patients were also screened for possible psychological distress. The study found that around 90 % providers did not possess a formal qualification but were a significant source of care provision. Providers' overall knowledge and practice of syndromic management was inadequate but these guidelines alone were inappropriate in relation to the care seekers's epidemiological and socio-cultural profile. Prevalence of infections in this population was low and some symptoms were associated with possible psychological distress. Communities' perceptions of genito-urinary illnesses were imbued with culturally influenced anxieties, that could potentially confound a clinical diagnosis. Providers too, commonly attributed symptoms to non-biomedical causes but persisted in dispensing biomedical drugs including antibiotics. Providers with a recognized qualification in an indigenous system of medicine displayed greater average technical skills than informally qualified ones, but both groups displayed similar knowledge levels. Knowledge was associated with technical performance at middle but not higher levels. All providers demonstrated moderate to high levels of interpersonal skills and these were strongly associated with increasing treatment charges. Providers were more likely to provide better technical quality to men and better interpersonal quality to women. As private providers with diverse qualifications meet a vast proportion of basic health care needs in rural areas, they all must be strengthened to provide an optimum quality of basic health care. The public health system needs to recognize private providers as an important first rung of primary health care in rural areas and establish strong referral and other supportive links with them. Providers' knowledge and skills upgradation needs to be combined with concerted behaviour change communication targeted at rural communities and regulation of the pahramaceutical industry for providers' drug dispensing to be rationalized. Health services for genito-urinary problems need to be expanded to cover pathological as well as psycho-sexual etiologies and management guidelines revised and evaluated. Health related IEC campaigns must allay fears and anxieties related to masturbation and loss of genital fluids in men and local secondary schools must intitiate comperehensive reproductive health education for adolescents at the earliest.